Jacksonville State University
Accelerated High School Application

Have you ever attended JSU?
Yes____ No____

If yes, it is not necessary to reapply.

A $20 non-refundable application fee must accompany this application.

Social Security Number:
 

Full Legal Name:

                      (Last)                               (First)                       (Middle)

Home Phone:

Other Phone:

Mailing Address:

City:

State/Zip:

County:

Citizenship:     USA       Other      
Specify Other:

Date of Birth:

Sex:   ____   Male   ____  Female

Voluntary Information(not used for admission):

Race: ___Black  ___Hispanic ___Asian/Pacific Islander_____American Indian/Alaskan
Native_____Other_____White 

Please list other Colleges/Universities, City, State and date of attendance below:
 
 
Term you plan to enter JSU:   Fall ____ (Yr)  Spring____ (Yr) May ____ (Yr)  Summer  I ____ (Yr)
                                                    Summer  II ____ (Yr)

I understand that withholding information requested in this application or giving false information
may make me ineligible for admission to, or continuation at, Jacksonville State University.  With
this in mind, I certify that all of this information it true,  correct and complete.  Further, if I am
admitted to Jacksonville State University, I agree to abide by the rules and regulations of  the
University.  My permission is given to the University to obtain information pertinent to my
academic record my high school.  In addition, I authorize JSU to release any information to
my high school official pertaining to my academic performance while enrolled as an
Accelerated High School student at JSU.

 Signature:__________________________________   Date:________________

 Male students who are United States citizens or U.S. permanent residents, between the ages
of 18-25 are required to register  with Selective Service.  If this applies to you, have you
registered with Selective Services:   Yes ____     No ____

(For more information see www.sss.gov)

 If you wish to request accommodations under The Americans with Disabilities Act or Section
504 of The Rehabilitation Act of  1973, as amended, contact JSU’s Office of Disability Support
Services at 256-782-5093.  Information regarding race, national  origin or disability status will
not be used for admission purposes.

 *The student’s social security number is confidential.  The use of the social security number
as student number is voluntary but must be supplied to JSU to fulfill the requirements of the
Tax Payer Relief Act of 1997.  Your student number must be your social security number if
you are applying for financial aid.  If a student decides not to use his/her social security
number as the student number, he/she must notify in writing the Office of Registrar of this
intent.  Any social security number used as a student number will not be released without
written consent from the student.  Authority for requesting the disclosure of a student’s
social security number is in Section 7 (a) (2) of the Privacy Act of 1974 (5 U.S.C. 522 a). 

Privacy Act

In accordance with the Family Educational Rights and Privacy Act of 1974, Jacksonville State University
considers the following information as Directory Information: “Student’s name, address, telephone listing,
date of birth, major field of study, participation in officially recognized activities and sports, weight and
height of the athletic teams, dates of attendance, degrees and awards received and the most previous
educational agency or institution attended by the student.”

If you do not want this information released.  YOU MUST SIGN A REQUEST in the Office of the Registrar
 no later than seven days after the formal registration period ends.  In order to remove this hold, you must
notify the Office of the Registrar in Writing.

 To Be Completed By High School Information and Authorization

High School Name:

Principal Name:

Address:

City:

State/Zip:

High School Phone:

Student Present Overall Grade Point Average:

Student Expected Graduation:

 ACT Score: _______________                           SAT Score: ______________           

Date taken: ________________                           Date taken: _______________

Attach a copy of ACT/SAT or placement scores for students who wish to take
English or Math courses.

This form is to be used by high school students who are applying for Accelerated High School
or Dual Enrollment/Dual Credit in area school systems and Jacksonville State University (JSU).

 Eligible students are permitted to enroll in college courses conducted during school hours, after
school hours and during summer terms.  Courses offered shall be drawn from JSU existing
academic inventory of 100-200 level courses for credit.  Courses numbered below 100 and
physical education courses are not eligible under this plan.  JSU reserves the right to cancel
course offerings when courses do not meet minimum enrollment requirements.

To be eligible for accelerated high school and/or dual enrollment each student must meet
the following criteria:

                 1.     Meet the entrance requirements established by JSU;

                2.     Have a “B” average in completed high school courses;

                3.     Have written approval of the appropriate principal and the local
superintendent of education, by completing this form;

                4.     Be in grades 10, 11, or 12, or have an exception granted by JSU upon the
 recommendation of the student’s principal and superintendent and in
accordance with Alabama Administrative Code 290-8.9.17 regarding
 gifted and talented students;

                5.      Accelerated students must maintain a “C” average or better in all attempted
coursework and a “B” average in high school work.

 I hereby certify that _______________________, meets all Accelerated High School
and/or Dual Enrollment/Dual Credit eligibility requirements as set out by the Alabama State
Board of education and above listed high school.  I request that this student be approved
for Accelerated High School and/or Dual Enrollment/Dual Credit Programs at
 Jacksonville State University.

  ______________________________                 ________________________
         Principal (type or print)                                          Principal (signature)
  and/or
  ______________________________                 ___________________________
                Counselor (type or print)                                Counselor (signature)

Please return signed application and $20 application fee to:

Academic Affairs
Jacksonville State Univesrity
700 Pelham Road North
Jacksonville, AL  36265-1602
Phone:  (256)782-5284
Fax:  (256)782-5220
Email:  crose@jsu.edu

 
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Last Update 05/10/06